1093710279 NPI number — LAURIE CHAMPAGNE ROUNDTREE OTR/L, CHT

Table of content: LAURIE CHAMPAGNE ROUNDTREE OTR/L, CHT (NPI 1093710279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093710279 NPI number — LAURIE CHAMPAGNE ROUNDTREE OTR/L, CHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROUNDTREE
Provider First Name:
LAURIE
Provider Middle Name:
CHAMPAGNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L, CHT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093710279
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 HODENCAMP RD
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
THOUSAND OAKS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91360-5831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-495-0516
Provider Business Mailing Address Fax Number:
805-381-9366

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 HODENCAMP RD
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
THOUSAND OAKS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91360-5831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-495-0516
Provider Business Practice Location Address Fax Number:
805-381-9366
Provider Enumeration Date:
06/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XH1200X , with the licence number:  OT4513 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4484430001 . This is a "DMERC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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